Reimbursement for healthcare has utilized a variety of payment mechanisms with varying degrees of effectiveness. Whether these mechanisms are used singly or in combination, it is imperative that the resulting systems remunerate on the basis of the quantity, complexity, and quality of care provided. Expanding the role of the electronic medical record (EMR) to monitor provider practice, patient responsiveness, and functioning of the healthcare organization has the potential to not only enhance the accuracy and efficiency of reimbursement mechanisms but also to improve the quality of medical care.

Pay for performance has been recommended by the Institute of Medicine as an incentive to improve the quality of health care, but it is important to separate provider contributions from other influencing factors within the health care system. If appropriate methodology is not used, much time, effort, and money may be expended in gathering data that may be potentially misleading or even useless, such that good performance may go unrecognized and mediocre performance may be rewarded.

Pay for performance has been recommended by the Institute of Medicine as an incentive to improve the quality of health care. Traditional quality-improvement methods may be adapted to evaluate performance of salaried providers, but it is important to separate provider contributions from other influencing factors within the health care system. Accurate recording, extraction, and analysis of data together with careful selection and measurement of indicators of performance are crucial for meaningful assessment. If appropriate methodology is not used, much time, effort, and money may be expended gathering data that may be potentially misleading or even useless, with the possibility that good performance may go unrecognized and mediocre performance rewarded.

An increase in levels of C‐reactive protein (CRP), a marker of systemic inflammation, is associated with reduced forced expiratory volume in 1 s (FEV1), supporting the hypothesis that the pathophysiology of chronic obstructive pulmonary disease has a systemic inflammatory component. However, few large studies have assessed the relationship between systemic inflammation as measured by CRP and decline in lung function prospectively in a randomly selected population.

Methods

In 1991, data were collected on FEV1 and forced vital capacity (FVC) and a blood sample was taken from 2442 randomly selected adults in a community‐based cohort. In 2000 these measures were repeated in 1301 individuals. The level of serum CRP was analysed in these samples from 1991 and 2000.

Results

In cross‐sectional analyses of data from 1991 and 2000, serum CRP levels were inversely related to FEV1 and FVC. After adjustment for smoking and other confounders, the difference in FEV1 was reduced by −9 ml (95% CI –13 to –5) and –7 ml (95% CI –13 to –2) for each mg/l increment in serum CRP in 1991 and 2000, respectively. There was no significant association between baseline serum CRP levels and decline in FEV1 and FVC over 9 years.

Conclusions

Although serum CRP levels are inversely associated with lung function in cross‐sectional studies, there was no effect of a marker of systemic inflammation on decline in lung function over 9 years.

Pulmonary function measures reflect respiratory health and predict mortality, and are used in the diagnosis of chronic obstructive pulmonary disease (COPD). We tested genome-wide association with the forced expiratory volume in 1 second (FEV1) and the ratio of FEV1 to forced vital capacity (FVC) in 48,201 individuals of European ancestry, with follow-up of top associations in up to an additional 46,411 individuals. We identified new regions showing association (combined P<5×10−8) with pulmonary function, in or near MFAP2, TGFB2, HDAC4, RARB, MECOM (EVI1), SPATA9, ARMC2, NCR3, ZKSCAN3, CDC123, C10orf11, LRP1, CCDC38, MMP15, CFDP1, and KCNE2. Identification of these 16 new loci may provide insight into the molecular mechanisms regulating pulmonary function and into molecular targets for future therapy to alleviate reduced lung function.

Rationale: Genomic loci are associated with FEV1 or the ratio of FEV1 to FVC in population samples, but their association with chronic obstructive pulmonary disease (COPD) has not yet been proven, nor have their combined effects on lung function and COPD been studied.

Objectives: To test association with COPD of variants at five loci (TNS1, GSTCD, HTR4, AGER, and THSD4) and to evaluate joint effects on lung function and COPD of these single-nucleotide polymorphisms (SNPs), and variants at the previously reported locus near HHIP.

Methods: By sampling from 12 population-based studies (n = 31,422), we obtained genotype data on 3,284 COPD case subjects and 17,538 control subjects for sentinel SNPs in TNS1, GSTCD, HTR4, AGER, and THSD4. In 24,648 individuals (including 2,890 COPD case subjects and 13,862 control subjects), we additionally obtained genotypes for rs12504628 near HHIP. Each allele associated with lung function decline at these six SNPs contributed to a risk score. We studied the association of the risk score to lung function and COPD.

The recent controversy over the “Baby Doe” regulations issued by the Department of Health and Human Services represents the culmination of a dilemma that has faced the medical and legal professions for more than a decade. Although they have not been upheld by the courts, the regulations express the position that withholding treatment from defective newborns may constitute discrimination on the basis of handicap and advocate mechanisms for the reporting of such practices. Legislation regarding this issue is pending at both the national and state levels. The rulings have been disputed by many medical and professional groups, which are working to provide acceptable alternatives.

Femoral impaction grafting requires vigorous impaction to obtain adequate stability without risk of fracture, but the force of impaction has not been determined. We determined this threshold force in a preliminary study using animal femurs.

Methods

Adult sow femurs were used because of their morphological similarity to human femurs in revision hip arthroplasty. 35 sow femurs were impacted with morselized bone chips and an increasing force was applied until the femur fractured. This allowed a threshold force to be established. 5 other femurs were impacted to this force and an Exeter stem was cemented into the neomedullary canal. A 28-mm Exeter head was attached and loaded by direct contact with a hydraulic testing machine. Axial cyclic loading was performed and the position sensor of the hydraulic testing machine measured the prosthetic head subsidence.

Results

29 tests were completed successfully. The threshold force was found to be 4 kN. There was no statistically significant correlation between the load at fracture and the cortex-to-canal ratio or the bone mineral density. Following impaction with a maximum force of 4 kN, the average axial subsidence was 0.28 mm.

Interpretation

We achieved a stable construct without fracture. Further studies using human cadaveric femurs should be done to determine the threshold force required for femoral impaction grafting in revision hip surgery.